Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Pecos during CMS and state inspections, most recent first.
Failure to provide required RN coverage: The facility did not use the services of an RN for at least 8 consecutive hours a day, 7 days a week on 3 reviewed days, and staffing records showed no RN assigned during those shifts. The DON and Administrator acknowledged the shortage of RNs, and the facility policy stated that an RN provides services at least 8 hours every 24 hours, 7 days a week.
A facility failed to maintain a working air conditioner in its van, preventing residents from being taken into the community for activities. In a group interview, several residents said they had not been able to go out to the store or other community activities because the van AC had been broken for months. The Maintenance Director, DON, and Administrator gave differing accounts of how long the AC had been out of service and described prior attempts to get it repaired, while the facility's Resident Rights Policy states residents have the right to a dignified existence.
Ombudsman Contact Information Not Posted in a Visible Resident Area: The facility’s only Ombudsman Program sign was posted on a small-print sticker on a wall leading into the 200 hall and was not viewable to residents. In interviews, 4 of 6 residents did not know how to contact the ombudsman or where to find the information, and the DON and Administrator stated the posting needed to be visible, large enough to read, and at eye level. The DON also stated the facility did not have a policy regarding Ombudsman posting.
Unsafe and Unrepaired Resident Environment: Surveyors found black particles on the 300 hall shower floor, exposed piping under sinks in multiple resident bathrooms and the memory care shower room, and a closet door off its hinge in one resident room. Residents affected had dementia or severe cognitive impairment, and care plans referenced safe environment, fall risk, or communication needs. The Maintenance Director said the holes under the sinks had been present for months and had not been replaced, while the Housekeeping Director, DON, and Administrator gave differing descriptions of the black particles in the shower room and acknowledged the area remained in use.
A facility failed to develop complete person-centered care plans for three residents. One resident with acute respiratory failure and severe cognitive impairment had oxygen therapy documented in the MDS and a continuous O2 order, but the care plan did not address oxygen use and no oxygen sign was posted outside the room. Another resident with severe dementia was observed smoking, yet the care plan did not address smoking. A third resident with PVD and complete dependence for personal hygiene had a care plan that did not include ADLs, despite needing assistance with personal care.
Improper Disposal of Disposable Razors in Shower Room: A community shower room had a tied plastic bag containing multiple disposable razors left on top of a wall-mounted container instead of being discarded in the sharps container. CNA, LVN, RN, and the Administrator all stated razors were to be disposed of in the sharps box after use, and the facility policy required contaminated sharps to be discarded immediately or as soon as feasible into designated containers.
Failure to Provide Ready Access to Hydration: Three residents with severe cognitive impairment and self-care deficits were observed multiple times without a hydration jug or cup of water in their rooms. Interviews with the Ombudsman, CNA, RN, DON, and Administrator showed inconsistent practices about when pitchers were filled and whether water was readily available, despite the facility policy requiring aides to provide and encourage bedside, snack, and meal fluids on a daily and routine basis.
Missing Oxygen Signage Outside Resident Rooms: Three residents receiving O2 therapy had oxygen concentrators at bedside, but no O2-in-use signage posted outside their room doors. One resident had acute respiratory failure with hypoxia and severe cognitive impairment, and two residents had COPD with active O2 orders. Staff stated the signs were meant to alert others to oxygen use and that the missing signage created a fire hazard.
Unlocked Medication Cart: Surveyors observed an unlocked med cart in the 200-hallway with no residents or staff present. The LVN, RN, DON, and Administrator stated the assigned nurse or med aide was responsible for keeping the cart locked when not in use, and the facility policy required med carts to be secured during med passes and locked whenever out of the nurse’s view.
Food storage and kitchen sanitation practices were not followed. Multiple food items in the refrigerator and freezer were not dated or labeled, several containers had dried drippings or residue, dry storage items had dust, and a box of potatoes contained a sprouting potato mixed with other potatoes. A kitchen employee was observed with a hair net not fully covering the hair, and an overflowing trash container was found next to clean dishes in the dishwashing area.
QAPI plan documentation was incomplete and did not describe an ongoing, facility-wide process for identifying and correcting quality deficiencies. Meeting templates for multiple months had blank Goal, Interventions, and Progress sections, and the PIP contained repeated handwritten notes about past surveys and ANE in-services. The DON stated the facility could not provide the in-services noted, said the notes appeared copied from month to month and could be false documentation, and reported there was no trending or tracking identified in the plan.
QAPI Program Not Implemented as Documented: The facility failed to carry out its QAPI plan by not showing data collection, analysis, or documented goals, interventions, and progress in monthly QAPI templates. The PIP contained repeated handwritten notes about prior surveys and ANE in-services, but the DON said the facility could not provide the in-services referenced, and she stated the notes were copied from month to month with no trending or tracking identified. The Administrator said QAPI meetings were held monthly with department leaders, but the record did not show active action plans or evaluation of issues.
The facility failed to report unwitnessed injuries of unknown source involving two residents to the State Survey Agency. One resident with dementia and no BIMS score was found with bruising and a laceration to the eye/forehead area and could not explain how the injury occurred. Another resident with severe cognitive impairment and a history of falls was found on the floor with a forehead laceration and a wrist laceration, was sent to the hospital, and also could not explain the event. The facility also did not complete reporting for a sprinkler system malfunction after a pipe burst and the system failed.
Failure to Investigate and Report Unwitnessed Injuries: The facility did not thoroughly investigate or timely report two unwitnessed injury events involving cognitively impaired residents. One resident with dementia had bruising and a laceration near the eye, and staff later stated the event was unwitnessed and should have been reported to the State Survey Agency. Another resident with Alzheimer’s disease and severe cognitive impairment was found on the floor with facial and wrist lacerations; staff and the DON acknowledged the unwitnessed fall required investigation and reporting, but it was not reported to the State Survey Agency.
A resident admitted with a wound, PVD, and GERD did not have a baseline care plan developed within 48 hours. The resident’s MDS showed intact cognition and documented assistance needs for multiple ADLs, but the care plan only addressed activities and a skin issue, not the resident’s medical conditions or ADL needs. During observation, the resident’s fingernails were jagged and long, and he said he had not been offered a nail trim since admission. Staff interviews confirmed the initial care plan was expected to be completed by nursing leadership and include ADLs.
Failure to Provide Nail Care: A cognitively intact male resident with PVD and dependence for personal hygiene was observed with jagged, overgrown fingernails and stated he had not been offered a nail trim since admission. Staff said aides were to monitor nails and notify nurses, while nurses were responsible for trimming nails as needed; the facility policy required daily cleaning and regular trimming to prevent infection and scratching.
Failure to Provide Foot Care: Two residents with severe cognitive impairment and ADL dependence did not receive proper toenail care. One resident's toenails were observed to be about an inch long, and he said he had not been offered trimming since admission. CNAs said they were to monitor nail length during showers and notify nurses, while the RN and administrator described inconsistent podiatry scheduling and unclear nail-monitoring frequency. The facility policy stated nail care includes daily cleaning and regular trimming.
Urinal Left in Community Shower Room: A plastic urinal containing yellow tinged urine was observed hanging in the community bathroom/shower room in the 300 hall. A CNA, LVN, DON, and the Administrator all stated urinals should not be left in the shower room and should be emptied, rinsed, documented, and returned to the resident's room; the facility policy also addressed standard precautions for exposure to bodily fluids.
Missing Abuse Training for DON: The facility failed to ensure the DON had current abuse training and failed to provide staff training on abuse, neglect, exploitation, misappropriation of resident property, and reporting procedures. Record review showed the DON’s file did not contain current abuse training, and interviews showed conflicting understanding of who was responsible for monitoring staff training. The facility policy stated nursing leadership monitors competency and training for nursing staff, including dementia care.
Missing Infection Prevention and Control Training for DON: The facility failed to ensure the DON had current Enhanced Barrier training as part of the mandatory infection prevention and control program. During record review and interviews, the DON said Nursing Management was responsible for keeping nursing staff up to date, while later stating staff were responsible for their own trainings and that she was responsible for nursing staff and self. The Administrator stated HR monitored staff trainings, and the facility policy said nursing leadership established and monitored competency requirements and trainings.
A resident with severe cognitive impairment, impaired communication, high fall risk, and multiple comorbidities was found in bed with the call light hanging from the privacy curtain about six feet away, out of reach. The resident reported he could not reach the call light and would have to yell for help. The care plan called for reminding the resident to use the call device and ensuring the call light was within reach, but this was not implemented. Multiple staff, including CNAs, a hospitality aide, an RN, the Administrator, and the DON, acknowledged that call lights were expected to be within residents’ reach and confirmed that the observed placement was not acceptable. Review of the facility’s call system policy showed no specific guidance on call light placement.
The facility did not ensure the water dispenser area used for residents was clean and well-maintained. The dispenser was found soiled with dirt, dust, and standing water, and the surrounding floors were dirty with cracked tiles. Staff, including an RN and the DON, were unaware of who was responsible for cleaning the dispenser or the area, and the Administrator confirmed no assignments had been made for this task.
Surveyors found that food items in the kitchen were not properly labeled, dated, or sealed, and expired or rotting foods were not removed. The kitchen and storage areas were not maintained in a clean condition, with food particles, trash, and sticky substances present on surfaces and equipment. These actions did not meet professional standards for food service safety.
The facility did not maintain safe operating conditions for kitchen equipment, as the spray nozzle in the dishwashing room continuously leaked and the oven was not functioning. Staff interviews confirmed these issues had persisted for months and were known to administration.
A resident with moderate dementia and behavioral disturbances was struck on the arm and shoulder by a CNA during incontinent care after the resident became combative and hit the CNA. The CNA admitted to the action, describing it as reflexive rather than intentional, and a witness reported the incident immediately. The resident was assessed and found to have no injuries or distress, and facility investigation confirmed the occurrence of abuse.
A resident dependent on PEG tube feeding was left with the head of the bed flat while the feeding pump was infusing, contrary to physician orders and facility policy. The CNA responsible did not pause the feeding or notify a nurse before lowering the bed, despite care plan instructions to keep the head elevated during feeding. This failure was confirmed by observation and staff interviews.
The facility did not ensure RN coverage for at least 8 consecutive hours on two occasions when the scheduled agency RN called in and the DON was unavailable. Staffing records and interviews confirmed the absence of RN coverage on these days, in violation of facility policy and regulatory requirements.
A CNA failed to perform hand hygiene between glove changes while providing incontinent care to a resident with a history of stroke, muscle weakness, and incontinence. The CNA changed gloves multiple times without washing or sanitizing hands, handled a soiled wound dressing, and then touched clean items without proper hand hygiene, contrary to facility policy. The DON and Administrator confirmed that correct infection control procedures were not followed during this care episode.
A resident with multiple health issues, including dementia and muscle weakness, was not properly assessed for transfer needs, leading to inadequate supervision and assistance. The facility's staff had inconsistent views on the resident's weight-bearing ability, and there was no formal transfer assessment process beyond initial admission. This resulted in a CNA performing a one-person transfer, contrary to the facility's policy requiring ongoing assessment and documentation of transfer needs.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, with multiple instances of improperly labeled and expired food items found in the refrigerator and dry pantry. Staff interviews confirmed the facility's protocol for labeling and discarding expired food, which was not followed.
The facility failed to obtain informed consent from two residents before administering medications, including Zoloft, Paxil, and Xanax, despite their cognitive intactness and the facility's policy requiring such consent.
The facility failed to provide RN coverage for at least 8 consecutive hours a day, 7 days a week, for 14 days between July and September 2023. The DON confirmed the lack of RN coverage and mentioned efforts to hire new RNs and use agency nurses, but consistency remains an issue.
The facility failed to ensure the accurate administering of drugs by not removing an expired TB vial from the medication room. An agency nurse was unaware of the responsibility for removing expired medications, and the DON confirmed that no one was assigned to check the medications. The Administrator acknowledged the expired vial and its potential ineffectiveness.
The facility failed to ensure proper labeling and storage of medications. The Hall 100 nurse medication cart contained undated and expired insulin pens, and discontinued controlled medications were not stored behind two locks as required. The DON and Administrator acknowledged these oversights, attributing them to a lack of monitoring and staff inattention.
A CNA failed to wash hands or use hand sanitizer between glove changes during incontinent care for a resident with a high risk of infections. Despite the facility's infection control policy and ongoing staff training, this lapse in protocol was observed, highlighting a critical failure in maintaining proper infection prevention and control practices.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, on 3 of 30 days reviewed for nursing services. Record review of the Nursing Facility's Daily Staffing for the cited dates showed there was no RN assigned during those shifts, and the facility failed to have an RN working on those days. During interviews, the DON stated there were potential risks to residents when an RN was not present at least 8 hours a day, every day, and gave examples involving LVNs being unable to call time of death and the need for an RN if a resident was DNR. The Administrator stated the facility was attempting to contract RNs through advertisement and acknowledged the facility was short of RNs, which resulted in documented days without an RN on site. The facility policy stated that a registered nurse provides services at least eight hours every 24 hours, seven days a week, and the cited regulation requires the facility to use the services of an RN for at least 8 consecutive hours a day, 7 days a week.
Failure to Maintain Van Air Conditioner Limited Community Outings
Penalty
Summary
The facility failed to treat residents with respect and dignity by not maintaining a working air conditioner in the facility van, which prevented residents from being taken into the community for activities. In a confidential group interview, 4 of 6 residents stated they had not been able to go out into the community because the van air conditioner was broken, and they said it had been broken for about 6 months. They stated it would be nice to be able to go to the store or participate in community activities. During interviews, the Maintenance Director stated the van air conditioner had not been working for a year and that he had taken the van to a shop in Midland on two occasions, but the shop did not work on it because they had too much work. He stated there was no documentation because the van was not touched. The DON stated she did not know how long it had been broken and said the van had been sent back from a shop due to the shop having too much work. The Administrator stated the air conditioner had not been working for 5 months, that the van had been placed out of commission for resident safety, and that residents had a right to go out into the community. Record review of the facility's Resident Rights Policy stated residents have the right to a dignified existence.
Ombudsman Contact Information Not Posted in a Visible Resident Area
Penalty
Summary
The facility failed to post the Long-Term Care Ombudsman program contact information in a location available for all residents and in a format that residents could readily see and use. During observation on 05/12/2026 at 3:00 PM, the ombudsman contact information was posted on the wall leading into the 200 hallway on a white sticker with small print, and it was not viewable to residents. The posting was the facility’s single Ombudsman Program sign. In confidential interviews, 4 of 6 residents did not know how to contact the ombudsman and did not know where to find the information in the facility. On 05/14/26, the DON stated postings had to be in a visible area, large enough to see, and at eye level, and she stated the current ombudsman information might be too small for residents to see. The Administrator also stated the posting had to be easily accessible, large enough to see, and at eye level for residents in wheelchairs, and he stated the current information was potentially too small. The DON further stated the Nursing Facility did not have a policy regarding the Ombudsman posting.
Unsafe and Unrepaired Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in multiple resident areas, including the 300 hall shower room, the memory care unit shower room, four resident bathrooms, and one resident room closet. Survey observations found black particles on the floor tiles of the 300 hall shower room, exposed piping under the sink in the memory care unit shower room, exposed piping under the sinks in four resident rooms, and a closet door off its hinge in one resident room. Resident #5 had a diagnosis of unspecified dementia with other behavioral disturbances and a care plan that included providing a safe environment. During observation, missing tiles under the sink in the resident’s restroom were noted, leaving exposed piping. Resident #23 had dementia without behavioral disturbance and a BIMS score of 03 indicating severe cognitive impairment; missing tiles under the sink in the resident’s restroom were observed, leaving exposed piping. Resident #27 had vascular dementia with a BIMS score of 00 and a care plan addressing fall risk and safe environment; missing tiles under the sink in the resident’s restroom were observed, leaving exposed piping. Resident #33 had dementia without behavioral disturbance and a BIMS score of 04 indicating severe cognitive impairment; missing tiles under the sink in the resident’s restroom were observed, leaving exposed piping. Resident #44 had dementia without behavioral disturbance and a care plan addressing communication problems; the closet door in the resident’s room was observed off its hinge and not opening or closing properly. The shower room on the 300 hall was observed with unknown black particles on the shower floor, and the memory care shower room was observed with missing sheetrock under the sink exposing pipes. The Maintenance Director stated the holes under the sinks had been present for 6 months or more and had never been replaced, and the black particles in the 300 hall shower room had been present for about one week. The Housekeeping Director stated the 300 hall shower room had mold for more than 3 months and that she had reported it in morning meetings. The DON stated the black particles were hard water stains and that the shower rooms were cleaned daily by housekeeping. The Administrator stated the black particle stain had been present for about 5 months and that the missing tiles and sheetrock needed to be replaced after plumbing repairs.
Care Plans Missing Oxygen, Smoking, and ADL Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 3 of 7 residents reviewed. Resident #37 had a diagnosis of acute respiratory failure with hypoxia, a BIMS score of 05 indicating severe cognitive impairment, and an MDS that identified oxygen therapy under special treatments. The resident’s care plan did not address oxygen therapy, even though the physician order required oxygen continuously via nasal cannula and allowed titration from 2 to 5 liters for shortness of breath or pulse oximetry less than 90 percent. An observation of the resident’s room showed an oxygen concentrator at bedside, and there was no oxygen signage posted outside the door. Resident #49 had a diagnosis of unspecified dementia with other behavioral disturbance and a quarterly MDS showing a BIMS score of 00, indicating severe cognitive impairment. The resident’s care plan, revised on 02/17/2026, did not address smoking. An observation showed the resident outside in the smoking area smoking a cigarette. During interviews, the DON, MDS Regional Nurse, and Administrator each stated that smoking should be included in the care plan so staff would be aware of the resident’s smoking status and safety needs, and they identified nursing, social work, the DON, and corporate MDS as responsible for keeping care plans updated. Resident #4 had a history of peripheral vascular disease and a BIMS score of 15, indicating cognitive intactness. The resident’s MDS showed complete dependence for personal hygiene, but the care plan revised on 05/12/2026 did not include ADLs. During an interview and observation, the resident stated he wanted his nails cut or trimmed because they were long and uncomfortable, and his jagged nails were observed to be about a quarter inch long. Staff interviews stated that the initial care plan should address baseline care needs, including ADLs, and that failure to do so could leave a resident without the assistance needed.
Improper Disposal of Disposable Razors in Shower Room
Penalty
Summary
The facility failed to ensure the resident environment was as free of accident hazards as possible in the 300-hallway community shower room. On 5/12/2026 at 10:28 AM, an observation revealed a white plastic trash bag tied closed and containing multiple disposable razors sitting on top of a container mounted on the wall in the shower room. During interviews on 5/14/2026, CNA B stated aides or nursing staff were responsible for disposing razors in the sharps containers in the shower and that CNAs and aides were trained to notify the floor nurse if the sharps containers were full or close to full so they could be replaced. LVN C stated razors were to be disposed of in the sharps box in the shower room and that aides should dispose of them. RN D stated CNAs were to dispose of razors in the sharps container after one use on residents and to notify nursing if the container was full or nearly full. The Administrator stated all disposable razors were to be disposed of in the sharps container for resident and staff safety and that it was not acceptable to leave them in a plastic bag where they were easily accessible to residents. Record review of the facility's Sharps Disposal policy stated contaminated sharps were to be discarded immediately or as soon as feasible into designated containers.
Failure to Provide Ready Access to Hydration
Penalty
Summary
The facility failed to ensure sufficient fluid intake was offered to maintain hydration and health for three residents who were reviewed for access to hydration. Resident #23 had dementia with severe cognitive impairment and needed setup or clean-up assistance for eating; observations on multiple occasions showed no hydration jug in the room, and the resident stated she only sometimes received water with pills. Resident #27 had vascular dementia with severe cognitive impairment and also needed setup or clean-up assistance for eating; observations on multiple occasions showed no hydration jug or cup of water in the room. Resident #33 had dementia with severe cognitive impairment, needed setup or clean-up assistance for eating, and had a care plan noting impaired cognition and a self-care performance deficit; observations on multiple occasions showed no hydration jug in the room. During interview, the Ombudsman stated that in the memory care unit residents did not receive drinks regularly and that only one pitcher was kept, which could delay access to more water because staff had to leave the unit to refill it. A CNA stated the unit had one pitcher of water and residents were given water in plastic cups if they asked for it, and that pitchers were washed and refilled on Monday, Wednesday, and Friday. The CNA also stated residents received fluids with meals and medications and that CNAs and nurses were responsible for ensuring residents had water or fluids to prevent dehydration. An RN stated pitchers were passed out three days a week and that residents should be provided fresh water and ice daily or multiple times a day, but she had been told pitchers were only filled on Monday, Wednesday, and Friday. The DON stated fresh water was passed Monday, Wednesday, and Friday by CNAs, but also said water could be refilled throughout the day if needed and that the schedule was only for washing pitchers. The Administrator stated water was provided with meals and CNAs would pass water throughout their shift, and that nursing and CNAs were responsible for ensuring water was being passed daily. The facility policy stated nurses' aides would provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis.
Missing Oxygen Signage Outside Resident Rooms
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for three residents who were receiving oxygen therapy because oxygen-in-use signage was not posted outside their room doors. Resident #37 had a history of acute respiratory failure with hypoxia, a BIMS score of 05, and an active order for continuous oxygen via nasal cannula with titration for shortness of breath or low pulse oximetry. An observation of the room found an oxygen concentrator at bedside, but no oxygen signage was posted outside the door, and the care plan did not address oxygen therapy. Resident #39 had a diagnosis of COPD, a BIMS score of 12, and an active order for oxygen at 2 liters per minute via nasal cannula. The care plan included oxygen therapy as ordered, and an observation of the room found an oxygen concentrator and a nebulizer machine at bedside. During the observation, the resident verbalized that she used oxygen throughout the day, but there was no oxygen signage posted outside the door. Resident #49 had a diagnosis of COPD, a BIMS score of 00, and an active order for oxygen therapy at 2 to 4 liters per minute via nasal cannula. An observation of the room found an oxygen concentrator at bedside, but there was no oxygen signage posted outside the door. Staff interviews confirmed that oxygen signs should be posted outside rooms of residents on oxygen, that the signs were intended to alert others to oxygen use, and that the signs were not placed correctly and had been removed.
Unlocked Medication Cart
Penalty
Summary
The facility failed to keep a medication cart locked in the 200-hallway, which was observed unlocked on 05/12/2026 at 8:36 AM. At the time of the observation, there were no residents or staff in the hall. The deficiency was identified during survey review of pharmaceutical services related to the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals. During interviews on 05/14/26, the LVN, RN, DON, and Administrator each stated that the nurse or medication aide assigned to the cart was responsible for keeping it locked when not in use, and that staff were also responsible for locking it if found open. The Administrator stated medication carts were to be locked anytime the nurse stepped away from them. Record review of the facility’s Security of Medication Cart policy, revised 04/2007, stated that medication carts must be secured during medication passes and securely locked at all times when out of the nurse’s view, and when not being used they must be locked and parked at the nurses’ station or inside the medication room.
Food Storage, Labeling, Sanitation, and Hair Restraint Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation on 5/12/2026, a container of soy sauce in the refrigerator had an unknown yellow jelly substance smeared on it, and containers of ranch dressing and salad dressing had dried drippings around their lids. Also observed in the refrigerator were trays of prepared fruit desserts, glasses of tea, and glasses of milk that were not dated or labeled. In the dry storage room, a storage container lid had dust on it, and in the freezer a container of vanilla ice cream had dried drippings on the side. Additional observations showed a package of pork loin meat, four packages of red meat, and a bag of chopped broccoli in the freezer that were not labeled or dated. A box of potatoes in dry storage contained a potato sprouting roots mixed with the other potatoes, and red peppers in the refrigerator drawers were not labeled or dated and were not in original packaging. The drink dispenser had dried residue on the handle and nozzle, and an overflowing garbage container was observed in the dishwashing area next to a cart of clean dishes. On 5/13/2026 and 5/14/2026, [NAME] E was observed in the kitchen with her hair net not fully covering her hair. In interviews, [NAME] E stated that food needed to be dated and labeled, containers needed to be wiped down after use, hair nets needed to fully cover hair, and the dietary manager was responsible for ensuring food was labeled, dated, and stored properly. The Dietary Manager stated that all kitchen staff were responsible for labeling food and maintaining cleanliness, that hair needed to be secured under hair nets, and that overflowing trash was unacceptable, especially near clean dishes. The Administrator stated that all food items should be dated and labeled upon receiving them, all staff needed to wear hair nets, and trash should be disposed of before it overfilled the can.
QAPI Plan Lacked Ongoing, Comprehensive Process and Documentation
Penalty
Summary
The facility failed to develop a QAPI plan that described the process for conducting quality assessment and assurance activities, including how the committee would identify and correct quality deficiencies. Record review of the Nursing Facility’s QAPI plan and meeting template documents for 02/2026, 03/2026, and 04/2026 showed that the areas for Goal, Interventions, and Progress were blank. The PIP for those 3 months contained the same handwritten notes stating that past LSC and Annual Surveys from 03/25/25-03/28/25 had all deficiencies identified with no current issues, and that ANE in-services were completed for the months mentioned. During interview and observation on 05/14/2026, the DON stated the facility was unable to provide the requested in-services noted on the PIP. She reviewed the handwritten QAPI notes and stated they were the Administrator’s notes and that he copied and pasted them from one month to the next, adding that this could be considered false documentation because the notes did not reflect current monthly training or progress on issues. She also stated there was no trending and tracking identified in the plan. The Regional Corporate Nurse stated she had just started in 03/2026 and there were no action plans until 04/2026. The Administrator stated he was responsible for QAPI and that department supervisors, the DON, the Medical Director, and he participated in monthly QAPI meetings where concerns or trends regarding residents and the Nursing Facility were discussed and identified.
QAPI Program Not Implemented as Documented
Penalty
Summary
The facility failed to implement its QAPI plan and program by not ensuring that data was gathered and analyzed, and that plans of action were developed, implemented, and evaluated to address adverse events related to potential deficient practice. Record review of the facility’s QAPI meeting templates for 02/2026, 03/2026, and 04/2026 showed the sections for Goal, Interventions, and Progress were blank. The PIP for those months contained the same handwritten notes stating that past LSC and Annual Surveys from 03/25/25-03/28/25 had all deficiencies identified with no current issues, and that ANE in-services were completed for the months noted. During interview, the DON stated the facility was unable to provide the requested in-services referenced in the PIP. The DON also stated the handwritten QAPI notes were the Administrator’s notes and that he copied and pasted them from one month to the next, adding that this could be considered false documentation and that there was no trending or tracking identified in the plan. The Regional Corporate Nurse stated she had just started in 03/2026 and there were no action plans until 04/2026. The Administrator stated he was responsible for QAPI and that monthly QAPI meetings included department supervisors, the Administrator, the DON, and the Medical Director, where concerns or trends regarding residents and the facility were discussed.
Failure to Report Unwitnessed Injuries and Sprinkler System Malfunction
Penalty
Summary
The facility failed to report suspected abuse, neglect, or injuries of unknown source to the State Survey Agency immediately, and no later than 2 hours after the allegation was made, for two residents who had unwitnessed injuries. Resident #44 had dementia without behavioral disturbance, no BIMS score on the quarterly MDS, and required substantial to maximal assistance for mobility tasks. Her care plan identified communication problems related to Alzheimer’s dementia and depression, and noted that staff were to anticipate and meet her needs. On 05/09/2026, staff found her with bruising around the right eye and a small skin tear/laceration above and beside the right eye. The incident was unwitnessed, and the resident was unable to state how the injury occurred. Neurological checks were completed and showed no changes, but the event was not reported to the State Survey Agency. Resident #7 had Alzheimer’s disease with behavioral disturbance, generalized muscle weakness, and a BIMS score of 0, indicating severe cognitive impairment. His care plan identified him as a fall risk and included interventions such as a fall mat, call light within reach, and bed in lowest position. On 05/02/2026, a nurse found him on the floor in the middle of his room facing his bed with a 1 cm facial laceration on the left forehead and a small laceration on the left wrist with bleeding from both sites. He was assessed, treated, sent to the hospital for further evaluation, and returned the same day with no acute findings on CT scan. The incident was investigated and the responsible parties, DON, administrator, and physician were notified, but it was not reported to the State Survey Agency. The report also identified a failure to report a sprinkler system malfunction. In January 2026, a pipe burst and the sprinkler system malfunctioned after freezing temperatures caused the pipes to burst. The administrator stated the fire department responded, fire watches were initiated, and the issue was repaired, but the incident was not followed up with the State Survey Agency as required. The facility policy stated that suspected abuse, neglect, exploitation, misappropriation, and injuries of unknown source must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines.
Failure to Investigate and Report Unwitnessed Injuries
Penalty
Summary
The facility failed to show evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the administrator or designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 2 residents reviewed for injuries of unknown origin. One resident, a female with dementia without behavioral disturbance, had bruising around the right eye and a laceration above the right eyebrow. The record showed she needed substantial to maximal assistance with mobility and had a care plan addressing communication problems related to Alzheimer’s dementia and depression, with interventions to anticipate and meet her needs. For that resident, an incident progress note stated a CNA entered the room to provide incontinent care and noticed bruising to the right eye and a small skin tear above the right eyebrow and on the side of the right eye. The note stated the resident had hit her head on the bedside dresser. The incident report stated the skin tear was cleansed and the DON and physician were notified. Neurological checks were documented with no changes, and on observation the resident had bruising around the right eye and a small laceration above the right eyebrow, but she was unable to verbalize what had happened or how the injuries were obtained. The DON later stated the incident was unwitnessed and that, because the resident could not state what happened, it should have been reported to the State Survey Agency. The second resident, a male with Alzheimer’s disease with behavioral disturbance and generalized muscle weakness, had a BIMS score of 0 and was severely cognitively impaired. His care plan identified him as at risk for falls due to Alzheimer’s disease and generalized muscle weakness, with interventions including a fall mat, call light within reach, and bed in lowest position. An incident report documented that he was found on the floor in the middle of his room with a 1 cm facial laceration to the left forehead and a small laceration on the left wrist with bleeding from both sites. He was assessed, treated, and sent to the hospital, where documentation showed no acute findings on CT scan and no new orders. In interview, staff stated the resident was found by himself, could not explain what happened, and the DON and Administrator acknowledged that the unwitnessed fall warranted investigation and reporting to HHSC, but the facility did not report it to the State Survey Agency.
Baseline care plan not developed within required timeframe
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #4 within 48 hours of admission. Resident #4 was admitted on 04/24/2026 and had a history that included a wound to the right fingers, Peripheral Vascular Disease, and GERD. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness, and Section GG documented assistance needs for eating, oral hygiene, personal hygiene, toilet hygiene, showering/bathing, and upper and lower body dressing. However, the care plan with revision date 05/12/2026 contained only three activity-related focus areas and one focus area related to an actual impairment to skin integrity of the left lower extremity related to a surgical wound. During observation and interview on 05/12/2026, Resident #4’s fingernails were observed to be jagged and about a quarter inch long from the nail bed, and the resident stated he wanted them trimmed because they were long and uncomfortable. He also stated he had not been offered a nail trim or cut since being in the facility. Staff interviews identified that the initial care plan was the responsibility of MDS nursing, an RN, the ADON, or the DON, depending on availability, and that ADLs were to be included in the care plan. The facility’s care planning policy stated that the interdisciplinary team was responsible for developing resident care plans according to state regulation, which requires a baseline care plan within 48 hours of admission.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to ensure that Resident #4, a cognitively intact male with a history of Peripheral Vascular Disease, received necessary assistance with grooming and personal hygiene. Resident #4’s MDS indicated he was completely dependent for personal hygiene, but his care plan revision did not include ADLs. During observation, his fingernails on both hands were noted to be jagged and about a quarter inch long from the nail bed, and he stated he wanted them trimmed because they were becoming long and uncomfortable. He also stated he had not been offered nail trimming since being in the facility. Staff interviews showed that nail care was expected to be monitored by nursing aides during shower days or as needed, with nurses responsible for providing nail cutting or trims. CNA A, LVN C, RN D, the DON, and the Administrator all acknowledged that residents’ fingernails were to be monitored and trimmed as needed, and that long or dirty nails could lead to injury or infection. The facility’s Care of Fingernails/Toenails policy stated that nail care includes daily cleaning and regular trimming to keep nails trimmed and prevent infections, and that trimmed, smooth nails help prevent accidental scratching and skin injury.
Failure to Provide Foot Care
Penalty
Summary
The facility failed to ensure proper foot care for two residents reviewed for foot care, Resident #7 and Resident #49. Resident #7 was a severely cognitively impaired male with a BIMS of 0, a history of Alzheimer's disease with behavioral disturbance and generalized muscle weakness, and was completely dependent for personal hygiene. His care plan indicated he required assistance with ADLs including personal hygiene. Resident #49 had a diagnosis of unspecified dementia with behavioral disturbance, a BIMS of 00 indicating severe cognitive impairment, and his care plan identified an ADL self-care performance deficit with interventions including assistance by one staff member with personal hygiene. During observation, Resident #49's toenails were noted to be long, extending about an inch from the nail bed, and he stated he wanted them trimmed and had not been offered toenail trimming since being in the facility. CNA A stated nursing aides were responsible for monitoring toenail length during shower days and notifying nurses if toenails were long or if a resident requested trimming. RN D stated the facility had no set podiatry schedule and nurses were responsible for helping schedule appointments when needed. The administrator stated a podiatrist came to the facility every 6 months and that nurses monitored residents' nails and toenails, though he was unsure how often. The facility's policy stated nail care includes daily cleaning and regular trimming to keep nails trimmed and prevent infections.
Urinal Left in Community Shower Room
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections in 1 of 2 shower rooms reviewed for infection control. During an observation of the community bathroom in the 300 hallway, a plastic urinal was seen hanging from the grab bar next to the toilet and it contained yellow tinged urine. During interviews, a CNA stated that urinals were to be emptied and rinsed after each use and should not be left in the shower room, and that CNAs were responsible for ensuring this was done. An LVN stated that urinals should not be left in the community shower room because of cross contamination possibility and that CNAs and nurses were responsible for ensuring they were either disposed of or kept in the resident's room. The DON and Administrator also stated that urinals were not to be left in the shower room and that CNAs were responsible for emptying, documenting output, rinsing the urinal, and returning it to the resident's room. Review of the facility's Infection Prevention and Control Policies and Procedures stated that health care workers would implement universal/standard precautions whenever there is occupational exposure to blood and bodily fluids to reduce the risk of transmission of microorganisms from recognized and unrecognized sources of infection.
Missing Abuse Training for DON
Penalty
Summary
The facility failed to provide training to staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, as well as the procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation. This deficiency was identified for 1 of 8 staff reviewed for abuse, neglect, and exploitation training, specifically the DON, whose personnel file did not show current abuse training completed. Record review with Human Resources on 05/14/2026 at 11:00 AM confirmed the DON's hire date was 11/23/2009 and that the DON did not have current abuse trainings completed. During interviews, Human Resources stated nursing management was responsible for ensuring nursing staff were up to date with trainings, while the DON stated all staff were responsible for their own trainings and that she was responsible as the DON for nursing staff and herself. The Administrator stated Human Resources was responsible for monitoring facility staff trainings. The facility policy titled "Staffing, Sufficient and Competent Nursing," dated 08/2022, stated staff must demonstrate skills and techniques necessary to care for resident needs, including dementia care, and that competency requirements and trainings for nursing staff are established and monitored by nursing leadership with input from the medical director.
Missing Infection Prevention and Control Training for DON
Penalty
Summary
The facility failed to provide mandatory infection prevention and control training that included written standards, policies, and procedures for the program for 1 of 8 staff reviewed, the DON. During an interview and record review with Human Resources on 05/14/2026 at 11:00 AM, it was found that the DON did not have current Enhanced Barrier training completed. The DON stated that Nursing Management was responsible for making sure nursing staff were up to date with their trainings. During a later interview on 05/14/2026 at 5:40 PM, the DON stated that all staff were responsible for their own trainings and that she was responsible as the DON for nursing staff and self. On 05/14/2026 at 7:00 PM, the Administrator stated Human Resources was responsible for monitoring facility staff's trainings. Record review of the Nursing Facility's Staffing, Sufficient and Competent Nursing policy dated 08/2022 stated that staff must demonstrate the skills and techniques necessary to care for resident needs and that competency requirements and trainings for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure nursing competency.
Failure to Ensure Accessible Call Light for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring the call light was within reach while the resident was in bed. During an observation, the resident was found lying in bed with the call light hanging from the privacy curtain toward the foot of the bed, approximately six feet away and not accessible to him. When asked, the resident stated he could not reach the call light and explained that if he needed help and could not reach it, he would yell until staff came to assist him. The resident was an elderly male with severe cognitive impairment, impaired communication, unsteadiness on his feet, repeated falls, dysphagia, malnutrition, orthostatic hypotension, hypertension, hyperlipidemia, metabolic encephalopathy, subclinical hypothyroidism, urinary tract infection, and benign prostatic hyperplasia. His MDS assessment showed a BIMS score of 04, indicating severe cognitive impairment, and documented that he required substantial to maximal assistance with bed mobility, transfers, toileting hygiene, dressing, and personal hygiene, and that he had impaired balance and was a high fall risk. His care plan identified multiple problem areas, including fall risk and impaired communication, and included interventions such as reminding him to use the call device and ensuring the call light was within reach. Multiple staff interviews confirmed that the call light was not within reach and that this placement was inconsistent with expectations. CNA staff, a hospitality aide, an RN, the Administrator, and the DON all stated that call lights were supposed to be within reach of residents, and several specifically noted that in this case the call light was clipped to or hanging from the privacy curtain away from the resident. The DON also stated that the resident had a prior fall and that fall precautions included placing the call light within reach, along with a low bed and fall mat. Review of the facility’s “Call System, Resident” policy did not reveal any specific language addressing the use, placement, or requirement of call lights.
Failure to Maintain Clean and Safe Water Dispenser Area
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the area housing the water dispenser used by residents. Observations revealed that the water dispenser was soiled with dirt and dust on the top and sides, and the interior contained dust and white spots, with standing water at the base. A cup half-filled with water was found sitting on top of the dispenser. The floors in the area were covered with dirt, and many of the floor tiles were cracked and broken. These conditions were directly observed during a survey. Interviews with staff, including an RN and the DON, indicated that the water dispenser was used to provide water to residents, particularly when taking medications or upon request. However, neither the RN nor the DON knew who was responsible for cleaning or maintaining the water dispenser or the surrounding area. The Administrator also confirmed that no one had been assigned to clean the dispenser or the area, and acknowledged the presence of dirt and broken tiles. Review of facility policy showed that cleaning tasks should be assigned and tracked, but this was not being followed for the water dispenser area.
Deficient Food Storage, Labeling, and Kitchen Sanitation
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, labeling, and cleanliness. In the dry storage area, several food items, including a bag of Idahoan potato slices, a multi-pack of graham cracker crusts, and a bag of white powder mix, were found open and not properly sealed. The dry storage also contained food particles and trash on the floor, and a box of potatoes with sprouting and rotting potatoes was present. In the freezer, a bag of rolls was not sealed. The refrigerator contained several items, such as Al Bondigas, tomato sauce, juice, and tea, that were labeled with dates but lacked use-by dates, and one pitcher of orange liquid was not labeled at all. Additionally, a storage dish of chicken noodle soup was found with a use-by date, but other items were missing this information. The bottom shelf of the refrigerator had dried sticky substances, and drawers used for utensils contained crumbs and a gritty substance. Further observations revealed that the juice machine dispenser spout had a sticky, reddish-brown substance build-up, and the dishwashing room floor had trash and debris in a corner. Despite a follow-up observation, the sprouting and rotting potatoes remained in dry storage. Review of facility policy and relevant food safety codes confirmed that these practices did not meet professional standards for food service safety, including requirements for proper labeling, dating, sealing, and cleanliness of food storage and preparation areas.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain all mechanical and electrical equipment in safe operating condition in the kitchen, as observed during a survey. The spray nozzle above the rinsing sink in the dishwashing room was found to have a steady flow of water even when in the off position, and the oven was not operational. The Chef confirmed that the oven was not working and that the spray nozzle had been leaking for several months, with the ADM being aware of both issues. The ADM stated that the spray nozzle had been repaired multiple times by maintenance but continued to break due to staff handling, and that replacement was delayed pending completion of an ownership change. These deficiencies were identified through direct observation, staff interviews, and record review.
Resident Struck by CNA During Care Resulting in Substantiated Abuse
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) hit a male resident with moderate dementia and multiple psychiatric diagnoses on the arm and shoulder during the provision of incontinent care. The incident took place while the resident was being changed and became combative, striking the CNA in the face and neck. In response, the CNA struck the resident on his arm and shoulder, an action witnessed by another CNA who immediately reported the event to facility management. The resident involved had a history of physical aggression related to dementia, ineffective coping skills, and poor impulse control, as documented in his care plan. At the time of the incident, the resident was assessed and found to have no injuries or signs of distress, and he did not recall the event when questioned. The CNA involved admitted to hitting the resident, describing her action as reflexive and not intentional, and the witness corroborated that the response did not appear to be out of anger but rather a reaction to being struck. Facility records confirmed that the CNA had received prior training on abuse prevention. The facility's policies emphasized the right of residents to be free from abuse and outlined procedures for staff training, identification, and reporting of abuse. Despite these policies and training, the incident occurred, and the facility's investigation substantiated that abuse had taken place.
Failure to Maintain Head of Bed Elevation During PEG Tube Feeding
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow established protocols for a resident receiving nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The resident, who had a history of stroke, muscle weakness, and dysphagia, was dependent on tube feeding and had physician orders and a care plan specifying that the head of the bed should be elevated at least 30 degrees during feeding and for a period after. During personal care, the CNA lowered the resident's bed to a flat position while the PEG tube feeding pump was still infusing formula, contrary to both the care plan and facility policy. The CNA later acknowledged that she normally would have called a nurse to pause the feeding pump before lowering the bed but forgot to do so during this instance. Both the Director of Nursing (DON) and the Administrator confirmed that the expected procedure was for CNAs to contact a nurse to pause the pump prior to lowering the bed. Facility policy also required the head of the bed to be elevated during tube feeding to prevent aspiration. The incident was observed and confirmed through interviews and record review.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, there was no RN coverage on two days in October 2024. Record review of the Payroll Based Journal and nurse staffing schedules confirmed the absence of RN coverage on these dates. The scheduled RN for those shifts was an agency employee who called in on the day of the shift, and the Director of Nursing (DON), who was the only other RN on staff at the time, was out of town and unable to cover the shifts. Attempts to secure a replacement RN from contracted staffing agencies were unsuccessful due to the last-minute nature of the call-ins. Interviews with the DON and the Administrator confirmed that the expectation was to have an RN present for at least 8 hours each day. Both acknowledged that the lack of RN coverage on the specified dates was due to last-minute call-ins and the unavailability of other RNs to cover the shifts. Facility policy also requires an RN to provide services for at least eight consecutive hours every 24 hours, seven days a week.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent care for a resident. The CNA did not wash or sanitize her hands between glove changes while providing care, despite multiple glove changes due to the resident continuing to have bowel movements. The CNA also removed a soiled wound dressing with her gloved hand and then, without changing gloves or performing hand hygiene, touched a clean brief and applied it to the resident. After removing her gloves, the CNA put on a new pair without sanitizing or washing her hands. The resident involved had a history of stroke, muscle weakness, dysphagia, and was always incontinent of both bladder and bowel, requiring regular incontinent care. The resident also had a wound dressing on the coccyx, which became soiled during the episode. The care plan for the resident specified maintaining cleanliness and dryness to prevent complications of incontinence, with staff expected to provide care after each episode of incontinence. Facility policies reviewed indicated that hand hygiene is the primary means to prevent infection, and that gloves do not replace handwashing. Staff are required to wash hands after removing gloves and before moving from a contaminated to a clean body site. The CNA acknowledged during interview that she forgot to perform hand hygiene between glove changes and after handling soiled items, which could lead to cross contamination. The DON and Administrator confirmed that the expected procedure was not followed during this episode of care.
Inadequate Supervision and Transfer Assessment for Non-Weight Bearing Resident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices for a resident who required transfers, as she was non-weight bearing. The resident, a female with diagnoses including heart failure, arthritis, dementia, and muscle weakness, was dependent on staff for transfers from bed to chair. However, her care plan and current assessments did not specify the number of staff required for safe transfers. During an observation, a CNA assisted the resident without locking the bed wheels and performed a one-person transfer, despite the resident's inability to bear weight. Interviews with staff revealed inconsistencies in understanding the resident's transfer needs. The CNA believed she could safely transfer the resident alone, while the LVN and DON had differing views on the resident's weight-bearing ability. The facility lacked a formal transfer assessment process beyond admission and re-admission, relying on staff communication for updates. The facility's policy required ongoing assessment and documentation of transfer needs, which was not adequately followed, leading to the deficiency.
Failure to Properly Label and Discard Expired Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed multiple instances of improperly labeled and expired food items in both the refrigerator and dry pantry. Specifically, red gelatin and a peanut butter and jelly mixture were found with dates exceeding their three-day shelf life, while ground beef, corn tortillas, and flour tortillas were found unlabeled and undated. Additionally, the dry pantry contained unlabeled sprinkles, expired red food coloring, expired Karo Syrup, and expired potato chips. Interviews with staff members, including Cook A and the Dietary Manager (DM), confirmed that the facility's protocol requires all food items to be labeled, dated, and discarded if expired. Cook A admitted to missing the labeling due to being busy with meal preparation. The DM stated that it is the responsibility of all staff to ensure food is properly labeled and discarded when expired. The Administrator acknowledged that the Dietary Manager is responsible for ensuring compliance with these standards. A review of the facility's document on food receiving and storage corroborated these requirements, indicating that all stored foods should be labeled and dated with a use-by date.
Failure to Obtain Informed Consent for Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments. Specifically, the facility did not obtain informed consent from two residents before administering medications. Resident #21, who had diagnoses including anxiety disorder, dementia, Alzheimer's disease, and moderate intellectual disabilities, was given Zoloft without documented consent. Despite having a BIMS score indicating cognitive intactness, there was no record of consent for the medication in her clinical records. Similarly, Resident #35, who had diagnoses including major depressive disorder, Type 2 Diabetes Mellitus, dysphagia, anxiety disorder, and end-stage renal failure, was administered Paxil and Xanax without documented consent. This resident also had a BIMS score indicating cognitive intactness, yet no consent was found in the clinical records for these medications. Interviews with the Director of Nursing (DON) revealed that consents are typically obtained by the receiving nurse, either directly from the resident or from the resident's responsible party. However, in these cases, the facility failed to obtain and document the necessary consents. The facility's policy on antipsychotic medication use, revised in December 2016, mandates that residents or their responsible parties be notified of physician recommendations for psychotropic/pharmacological interventions and provide consent for the use of such medications. The lack of documented consent for these medications indicates a failure to adhere to this policy, potentially placing residents at risk of receiving medications without their prior knowledge or consent.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 14 of 92 days between July 2023 and September 2023. Specifically, there was no RN coverage on 07/15/2023, 07/16/2023, 07/22/2023, 07/29/2023, 08/12/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/03/2023, 09/16/2023, 09/17/2023, 09/24/2023, and 09/30/2023. This deficiency was confirmed through a review of the facility's time sheets and an interview with the Director of Nurses (DON), who acknowledged the lack of RN coverage on the specified dates. The DON stated that the facility has been attempting to hire new RNs by offering competitive pay, sign-on bonuses, and benefits, and has also started using agency nurses, but consistency in RN coverage remains a challenge.
Expired TB Vial Found in Medication Room
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate administering of all drugs to meet the needs of the residents. During an inspection of the medication room, an expired Tuberculin (TB) vial was found in the refrigerator. The vial had been opened on 12/22/23 and should have been discarded after 30 days, but it was still present on 02/20/24. LVN C, an agency nurse, was unaware of who was responsible for removing expired medications and had not noticed the expired TB vial. The Director of Nursing (DON) confirmed that each nurse was responsible for dating and disposing of TB vials when expired, but acknowledged that no one was specifically assigned to check the medications in the medication room. The Administrator also confirmed the expired TB vial and stated that its use could lead to false readings or ineffectiveness. The facility's policy on medication labeling and the manufacturer's pamphlet for Tuberculin both indicated that opened vials should be discarded after 30 days, which was not followed in this instance.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. Specifically, the Hall 100 nurse medication cart contained six insulin pens without open dates and one expired insulin pen. The Licensed Vocational Nurse (LVN) responsible for the cart admitted to not noticing the missing dates and stated that she worked for an agency, so she did not always work at this facility. The Director of Nursing (DON) acknowledged that insulin pens should be dated when opened and disposed of when expired, but there was no designated person to monitor this process. The DON admitted that the failure occurred because no one was assigned to ensure insulin pens were properly dated and disposed of when expired. Additionally, the facility's policy required that all medications be properly labeled with expiration dates and directions for use, which was not followed in this instance. The facility also failed to ensure that discontinued controlled medications were stored in separately locked and permanently affixed compartments. During an inspection of the DON's office, it was found that seven blister packs containing controlled medications were stored in a large cabinet with only one lock, instead of the required two locks. The DON admitted that the medications were placed in the cabinet without the second lock due to her oversight. The Administrator confirmed that staff were supposed to date medications when opened and discard them after they expired, and that discontinued controlled medications should be kept behind two locks as per their protocol. The failure to follow these protocols was attributed to staff not paying attention and the DON getting distracted.
Infection Control Lapse During Incontinent Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the actions of CNA A during incontinent care for Resident #43. CNA A did not wash hands or use hand sanitizer between glove changes while assisting the resident, who has a history of hemiplegia, Type 2 Diabetes Mellitus, and cerebrovascular disease. This lapse in protocol was observed during an incontinent care procedure where CNA A changed gloves multiple times without performing hand hygiene, which is a critical step in preventing the spread of infection. The resident's care plan indicated a high risk for infections, making adherence to infection control practices even more crucial. Interviews with CNA A, the ADON, the DON, and the Administrator revealed a consensus on the importance of hand hygiene in preventing infections. CNA A admitted to forgetting to wash hands due to nervousness, while the ADON acknowledged the challenge of ensuring compliance among agency staff but emphasized that hand hygiene procedures are universal. The DON outlined the correct steps for incontinent care, which include handwashing and using hand sanitizer between glove changes. The facility's infection control policy also mandates hand hygiene before and after direct contact with residents and after removing gloves. Despite ongoing staff training, the failure to follow these procedures was evident in this incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pecos
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Monahans | 39.1 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.